<%@ page language="java" contentType="text/html; charset=UTF-8"   pageEncoding="UTF-8"%>
<%
	String contextPath = request.getContextPath();
%>
<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN" "http://www.w3.org/TR/html4/loose.dtd">
<html>
<head>
<meta http-equiv="Content-Type" content="text/html; charset=ISO-8859-1">
<link href="<%=contextPath%>/assets/stylesheets/bootstrap.min.css" rel="stylesheet" type="text/css">
<link href="<%=contextPath%>/assets/stylesheets/pixel-admin.min.css" rel="stylesheet" type="text/css">
<link href="<%=contextPath%>/assets/stylesheets/pages.min.css" rel="stylesheet" type="text/css">
<link href="<%=contextPath%>/assets/stylesheets/rtl.min.css" rel="stylesheet" type="text/css">
<link href="<%=contextPath%>/assets/stylesheets/themes.min.css" rel="stylesheet" type="text/css">
<link href="<%=contextPath%>/assets/stylesheets/select2.min.css" rel="stylesheet" type="text/css">
</head>
<body class="theme-default page-signup-alt">
	
	<form class="panel form-horizontal" id="jq-validation-form" action="index.html" style="width:1000px">
		<div class="row">
			<div class="col-sm-12">
				<div class="row">
					<div class="col-sm-12">
						<div class="form-group no-margin-hr">
							<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Has the
					 abuse case been contacted?</h1></label>
					 		<select>
								<option>No</option>
								<option>Yes</option>
							</select>
						</div>
					</div>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-2">
				<div class="form-group no-margin-hr">
					<label class="control-label">Date Contacted</label>
				</div>
			</div>
			<div class="col-sm-3">
				<div class="input-group date bs-datepicker-component">
					<input type="text" class="form-control"><span class="input-group-addon"><i class="fa fa-calendar"></i></span>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">By who?</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="checkbox-inline">
						<input type="checkbox" class="px" value="option1" id="inlineCheckbox1"> <span class="lbl">CCHR International</span>
					</label>			
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Staff Member First Name:</label>
						</div>
					</div>
					<div class="col-sm-6">
						<input type="text" class="form-control" name="firstname" placeholder="Staff Member First Name">
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Staff Member Last Name:</label>
						</div>
					</div>
					<div class="col-sm-6">
						<input type="text" class="form-control" name="firstname" placeholder="Staff Member Last Name">
					</div>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="checkbox-inline">
						<input type="checkbox" class="px" value="option1" id="inlineCheckbox1"> <span class="lbl">CCHR Chapter</span>
					</label>			
				</div>
			</div>
		</div>
		<div class="row">
			<div class="form-group no-margin-hr">
				<label class="col-sm-2 control-label">Which Chapter?</label>
				<div class="col-sm-2">
					<input type="text" class="form-control" name="lastname" placeholder="Staff Member First Name">
				</div>
				<label class="col-sm-2 control-label">Staff Member First Name</label>
				<div class="col-sm-2">
					<input type="text" class="form-control" name="lastname" placeholder="Staff Member First Name">
				</div>
				<label class="col-sm-2 control-label">Staff Member Last Name</label>
				<div class="col-sm-2">
					<input type="text" class="form-control" name="lastname" placeholder="Staff Member Last Name">
				</div>
			</div>
		</div>
		<div class="row">
			<label class="col-sm-2 control-label">Contacted by:</label>
			<div class="col-sm-1">
				<div class="form-group no-margin-hr">
					<label class="checkbox-inline">
						<input type="checkbox" class="px" value="option1" id="inlineCheckbox1"> <span class="lbl">Phone</span>
					</label>			
				</div>
			</div>
			<div class="col-sm-1">
				<div class="form-group no-margin-hr">
					<label class="checkbox-inline">
						<input type="checkbox" class="px" value="option1" id="inlineCheckbox1"> <span class="lbl">Email</span>
					</label>			
				</div>
			</div>
			<div class="col-sm-1">
				<div class="form-group no-margin-hr">
					<label class="checkbox-inline">
						<input type="checkbox" class="px" value="option1" id="inlineCheckbox1"> <span class="lbl">Letter</span>
					</label>			
				</div>
			</div>
			<div class="col-sm-2">
				<div class="form-group no-margin-hr">
					<label class="checkbox-inline">
						<input type="checkbox" class="px" value="option1" id="inlineCheckbox1"> <span class="lbl">In person</span>
					</label>			
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Did the abused person use insurance?</h1></label>
					<select>
						<option>yes</option>
						<option>no</option>
					</select>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">If yes,what type was used?</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-2">
				<div class="form-group no-margin-hr">
					<label class="checkbox-inline">
						<input type="checkbox" class="px" value="option1" id="inlineCheckbox1"> <span class="lbl">Private Insurance</span>
					</label>			
				</div>
			</div>
			<div class="col-sm-2">
				<div class="form-group no-margin-hr">
					<label class="checkbox-inline">
						<input type="checkbox" class="px" value="option1" id="inlineCheckbox1"> <span class="lbl">Medical</span>
					</label>			
				</div>
			</div>
			<div class="col-sm-2">
				<div class="form-group no-margin-hr">
					<label class="checkbox-inline">
						<input type="checkbox" class="px" value="option1" id="inlineCheckbox1"> <span class="lbl">Medicaid</span>
					</label>			
				</div>
			</div>
			<div class="col-sm-2">
				<div class="form-group no-margin-hr">
					<label class="checkbox-inline">
						<input type="checkbox" class="px" value="option1" id="inlineCheckbox1"> <span class="lbl">Other</span>
					</label>			
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-6">
						<div class="form-group no-margin-hr">
							<label class="control-label">Insurance Company Name:</label>
						</div>
					</div>
					<div class="col-sm-6">
						<input type="text" class="form-control" name="firstname" placeholder="Insurance Company Name">
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-6">
						<div class="form-group no-margin-hr">
							<label class="control-label">Insurance Company Name:</label>
						</div>
					</div>
					<div class="col-sm-6">
						<input type="text" class="form-control" name="firstname" placeholder="Insurance Company Name">
					</div>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">Notes on Insurance Details</label>				
				</div>
			</div>
			<div class="col-sm-9">
				<div class="form-group no-margin-hr">
					<textarea rows="3" class="form-control"></textarea>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Attorney Status:</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-2">
				<div class="form-group no-margin-hr">
					<label class="checkbox-inline">
						<input type="checkbox" class="px" value="option1" id="inlineCheckbox1"> <span class="lbl">Has attorney</span>
					</label>			
				</div>
			</div>
			<div class="col-sm-2">
				<div class="form-group no-margin-hr">
					<label class="checkbox-inline">
						<input type="checkbox" class="px" value="option1" id="inlineCheckbox1"> <span class="lbl">Wants attorney</span>
					</label>			
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="checkbox-inline">
						<input type="checkbox" class="px" value="option1" id="inlineCheckbox1"> <span class="lbl">No interest in attorney</span>
					</label>			
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-6">
						<div class="form-group no-margin-hr">
							<label class="control-label">Attorney First Name</label>
						</div>
					</div>
					<div class="col-sm-6">
						<input type="text" class="form-control" name="lastname" placeholder="Attorney First Name">
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-6">
						<div class="form-group no-margin-hr">
							<label class="control-label">Attorney Last Name</label>
						</div>
					</div>
					<div class="col-sm-6">
						<input type="text" class="form-control" name="lastname" placeholder="Attorney Last Name">
					</div>
				</div>
			</div>
		</div>
		 <div class="row">
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">Notes on Attorney status</label>				
				</div>
			</div>
			<div class="col-sm-9">
				<div class="form-group no-margin-hr">
					<textarea rows="3" class="form-control"></textarea>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Abused Case Referred to Attorney?</h1></label>
					<select>
						<option>yes</option>
						<option>no</option>
					</select>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Attorney First Name</label>
					<input type="text" class="form-control" name="firstname" placeholder="First Name">
				</div>
			</div>
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Attorney Last Name</label>
					<input type="text" class="form-control" name="middlename" placeholder="Middle Name">
				</div>
			</div>
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Date Referred</label>
					<div class="input-group date" id="bs-datepicker-component">
						<input type="text" class="form-control"><span class="input-group-addon"><i class="fa fa-calendar"></i></span>
					</div>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">Date Accepted</label>
						</div>
					</div>
					<div class="col-sm-9">
						<div class="input-group date" id="bs-datepicker-component">
							<input type="text" class="form-control"><span class="input-group-addon"><i class="fa fa-calendar"></i></span>
						</div>
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="row">				
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">Reason,if given</label>
						</div>
					</div>
					<div class="col-sm-9">
						<input type="text" class="form-control" name="lastname" placeholder="Staff Member First Name">			
					</div>
				</div>
				<div class="row">
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">Date Accepted</label>
						</div>
					</div>
					<div class="col-sm-9">
						<div class="input-group date" id="bs-datepicker-component">
							<input type="text" class="form-control"><span class="input-group-addon"><i class="fa fa-calendar"></i></span>
						</div>
					</div>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">Notes on Attorney Referral</label>				
				</div>
			</div>
			<div class="col-sm-9">
				<div class="form-group no-margin-hr">
					<textarea rows="3" class="form-control"></textarea>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Has a compliant been filed on this abuse?</h1></label>
					<select>
						<option>No</option>
						<option>Yes</option>
					</select>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-2">
				<div class="form-group no-margin-hr">
					<label class="control-label">Date Field</label>
				</div>
			</div>
			<div class="col-sm-3">
				<div class="input-group date bs-datepicker-component">
					<input type="text" class="form-control"><span class="input-group-addon"><i class="fa fa-calendar"></i></span>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Agency the compliant was filed with:</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">Agency Name</label>
						</div>
					</div>
					<div class="col-sm-8">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="lastname" placeholder="Agency Name">
						</div>
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">Contact Name</label>
						</div>
					</div>
					<div class="col-sm-8">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="lastname" placeholder="Contact Name">
						</div>
					</div>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-4">
				<div class="row">
					<div class="col-sm-5">
						<div class="form-group no-margin-hr">
							<label class="control-label">Street Address</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="lastname" placeholder="Street Address">
						</div>
					</div>
				</div>
			</div>
			<div class="col-sm-4">
				<div class="row">
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<label class="control-label">City/Province</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="lastname" placeholder="City/Province">
						</div>
					</div>
				</div>
			</div>
			<div class="col-sm-4">
				<div class="row">
					<div class="col-sm-2">
						<div class="form-group no-margin-hr">
							<label class="control-label">State</label>
						</div>
					</div>
					<div class="col-sm-7">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="lastname" placeholder="State">
						</div>
					</div>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">Zip/Postal Code</label>
						</div>
					</div>
					<div class="col-sm-8">
						<div class="form-group no-margin-hr">
							<input type="text" class="form-control" name="lastname" placeholder="Zip/Postal Code">
						</div>
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-2">
						<div class="form-group no-margin-hr">
							<label class="control-label">Country</label>
						</div>
					</div>
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<select class="form-control">
								<option>USA</option>
								<option>CHINA</option>
							</select>
						</div>
					</div>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-8">
						<div class="form-group no-margin-hr">
							<label class="control-label">Was a response received on the compliant?</label>
						</div>
					</div>
					<div class="4">
						<select>
							<option>yes</option>
							<option>no</option>
						</select>
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-4">
						<div class="form-group no-margin-hr">
							<label class="control-label">What was the response?</label>				
						</div>
					</div>
					<div class="col-sm-8">
						<div class="form-group no-margin-hr">
							<textarea rows="3" class="form-control"></textarea>
						</div>
					</div>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-2">
				<div class="form-group no-margin-hr">
					<label class="control-label">Notes on Compliant Field?</label>				
				</div>
			</div>
			<div class="col-sm-8">
				<div class="form-group no-margin-hr">
					<textarea rows="3" class="form-control"></textarea>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-10">
						<div class="form-group no-margin-hr">
							<label class="control-label">Has the abused person sined a general waiver?</label>
						</div>
					</div>
					<div class="col-sm-2">
						<select>
							<option>yes</option>
							<option>no</option>
						</select>
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">Date Signed</label>
						</div>
					</div>
					<div class="col-sm-8">
						<div class="input-group date" id="bs-datepicker-component">
							<input type="text" class="form-control"><span class="input-group-addon"><i class="fa fa-calendar"></i></span>
						</div>
					</div>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-10">
						<div class="form-group no-margin-hr">
							<label class="control-label">Has CCHR received documents from the abused? </label>
						</div>
					</div>
					<div class="col-sm-2">
						<select>
							<option>yes</option>
							<option>no</option>
						</select>
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">Date Received</label>
						</div>
					</div>
					<div class="col-sm-8">
						<div class="input-group date" id="bs-datepicker-component">
							<input type="text" class="form-control"><span class="input-group-addon"><i class="fa fa-calendar"></i></span>
						</div>
					</div>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Other Acitons Taken on the Case</label>				
				</div>
			</div>
			<div class="col-sm-8">
				<div class="form-group no-margin-hr">
					<textarea rows="3" class="form-control"></textarea>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Currents Status on the Case</label>				
				</div>
			</div>
			<div class="col-sm-8">
				<div class="form-group no-margin-hr">
					<textarea rows="3" class="form-control"></textarea>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">Date Case was Last Updated</label>
						</div>
					</div>
					<div class="col-sm-8">
						<div class="input-group date" id="bs-datepicker-component">
							<input type="text" class="form-control"><span class="input-group-addon"><i class="fa fa-calendar"></i></span>
						</div>
					</div>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="row">
					<div class="col-sm-3">
						<div class="form-group no-margin-hr">
							<label class="control-label">Case Category </label>
						</div>
					</div>
					<div class="col-sm-2">
						<div class="form-group no-margin-hr">
							<select class="form-control">
								<option>1</option>
								<option>2</option>
							</select>
						</div>
					</div>
				</div>
			</div>
		</div>
		<br>
		<div class="form-actions">
			<input type="submit" value="Submit" class="btn btn-primary btn-lg btn-block">
		</div>
	</form>



	
<!-- Javascript -->
	<script>var init = [];</script>
	<script>
		init.push(function () {

			$('.bs-datepicker-component').datepicker();
			
			var options2 = {
				orientation: $('body').hasClass('right-to-left') ? "auto right" : 'auto auto'
			}
			$('#bs-datepicker-range').datepicker(options2);
		});
		window.PixelAdmin.start(init);
	</script>

</body>
</html>